US 20100305685 A1
A surgical sutureless valve that is attached to a stent frame for delivery to a location in a patient using percutaneous implantation devices and methods.
1. A stented valve comprising:
a compressible and expandable stent structure comprising a generally tubular body portion having an interior area and a longitudinal axis; and
a bioprosthetic valve positioned at least partially within the interior area of the tubular body portion of the stent structure and comprising:
an outer tubular portion comprising at least two commissure extensions and an inner wall from which a plurality of leaflets extend; and
at least one scalloped portion extending between adjacent commissure extensions;
wherein the at least two commissure extensions are secured to the stent structure with attachment material that is slideable along the stent structure to allow for free movement of the valve relative to the stent structure along its longitudinal axis.
2. The stented valve of
3. The stented valve of
4. The stented valve of
5. The stented valve of
6. The stented valve of
7. The stented valve of
8. The stented valve of
9. A stented valve comprising:
a compressible and expandable stent structure comprising a generally tubular body portion having an interior area, an external surface, a longitudinal axis, an inflow end, and an outflow end;
a tubular tissue material at least partially covering the external surface of the stent structure and extending beyond the outflow end of the stent structure; and
a plurality of leaflets attached to the interior area of the stent
10. The stented valve of
11. The stented valve of
12. The stented valve of
13. The stented valve of
The present invention relates to prosthetic heart valves. More particularly, it relates to surgical sutureless valves and methods for percutaneously implanting such prosthetic heart valves in combination with a stent structure.
Diseased or otherwise deficient heart valves can be repaired or replaced using a variety of different types of heart valve surgeries. Typical heart valve surgeries involve an open-heart surgical procedure that is conducted under general anesthesia, during which the heart is stopped while blood flow is controlled by a heart-lung bypass machine. This type of valve surgery is highly invasive and exposes the patient to a number of potentially serious risks, such as infection, stroke, renal failure, and adverse effects associated with use of the heart-lung machine, for example.
Recently, there has been increasing interest in minimally invasive and percutaneous replacement of cardiac valves. Such surgical techniques involve making a very small opening in the skin of the patient into which a valve assembly is inserted in the body and delivered to the heart via a delivery device similar to a catheter. For certain applications, the technique is preferable to more invasive forms of surgery, such as the open-heart surgical procedure described above. In the context of pulmonary valve replacement, U.S. Patent Application Publication Nos. 2003/0199971 A1 and 2003/0199963 A1, both filed by Tower, et al., describe a valved segment of bovine jugular vein, mounted within an expandable stent, for use as a replacement pulmonary valve. The replacement valve is mounted on a balloon catheter and delivered percutaneously via the vascular system to the location of the failed pulmonary valve and expanded by the balloon to compress the valve leaflets against the right ventricular outflow tract, anchoring and sealing the replacement valve. As described in the articles: “Percutaneous Insertion of the Pulmonary Valve”, Bonhoeffer, et al., Journal of the American College of Cardiology 2002; 39: 1664-1669 and “Transcatheter Replacement of a Bovine Valve in Pulmonary Position”, Bonhoeffer, et al., Circulation 2000; 102: 813-816, the replacement pulmonary valve may be implanted to replace native pulmonary valves or prosthetic pulmonary valves located in valved conduits.
Various types and configurations of prosthetic heart valves are used in percutaneous valve procedures to replace diseased natural human heart valves. The actual shape and configuration of any particular prosthetic heart valve is dependent to some extent upon the valve being replaced (i.e., mitral valve, tricuspid valve, aortic valve, or pulmonary valve). In general, the prosthetic heart valve designs attempt to replicate the function of the valve being replaced and thus will include valve leaflet-like structures used with either bioprostheses or mechanical heart valve prostheses. In other words, the replacement valves may include a valved vein segment that is mounted in some manner within an expandable stent to make a stented valve. In order to prepare such a valve for percutaneous implantation, the stented valve can be initially provided in an expanded or uncrimped condition, then crimped or compressed around the balloon portion of a catheter until it is as close to the diameter of the catheter as possible.
Other percutaneously-delivered prosthetic heart valves have been suggested that have a generally similar configuration, such as by Bonhoeffer, P. et al., “Transcatheter Implantation of a Bovine Valve in Pulmonary Position.” Circulation, 2002; 102:813-816, and by Cribier, A. et al. “Percutaneous Transcatheter Implantation of an Aortic Valve Prosthesis for Calcific Aortic Stenosis.” Circulation, 2002; 106:3006-3008, the disclosures of which are incorporated herein by reference. These techniques rely at least partially upon a frictional type of engagement between the expanded support structure and the native tissue to maintain a position of the delivered prosthesis, although the stents can also become at least partially embedded in the surrounding tissue in response to the radial force provided by the stent and balloons that are sometimes used to expand the stent. Thus, with these transcatheter techniques, conventional sewing of the prosthetic heart valve to the patient's native tissue is not necessary. Similarly, in an article by Bonhoeffer, P. et al. titled “Percutaneous Insertion of the Pulmonary Valve.” J Am Coll Cardiol, 2002; 39:1664-1669, the disclosure of which is incorporated herein by reference, percutaneous delivery of a biological valve is described. The valve is sutured to an expandable stent within a previously implanted valved or non-valved conduit, or a previously implanted valve. Again, radial expansion of the secondary valve stent is used for placing and maintaining the replacement valve.
Although there have been advances in percutaneous valve replacement techniques and devices, there is a continued desire to provide different designs of cardiac valves that can be implanted in a minimally invasive and/or percutaneous manner.
Certain surgically implanted prosthetic heart valves, such as the aortic root bioprostheses commercially available under the trade designation “Freestyle” from Medtronic, Inc., of Minneapolis, Minn., have proven to have certain advantages over other bioprostheses used in aortic valve replacement. However, the implantation of these Freestyle types of valves is limited to surgeons who have become specifically skilled in the surgical implantation of homografts. The replacement heart valves of the invention are provided to overcome these limitations and are directed to attachment of a surgical heart valve into a patient without the use of sutures. In this way, the advantages of certain surgical valves can be achieved without the disadvantages of surgical valve implantation procedures. That is, the invention provides a sutureless implantation of a surgical valve, such as an aortic root bioprosthesis, which would typically be implanted into a patient using more traditional surgical techniques. The prosthetic heart valves of the invention include valves that are compressible to a relatively small diameter for percutaneous delivery to the heart of the patient, and then are expandable either via removal of external compressive forces (e.g., self-expanding stents), or through application of an outward radial force (e.g., balloon expandable stents).
The replacement heart valves of the invention include a stent to which a valve structure is attached. The stents of the invention include a wide variety of structures and features that can be used alone or in combination with features of other stents of the invention and are conducive to percutaneous delivery thereof.
Methods for insertion of the replacement heart valves of the invention include delivery systems that can maintain the stent structures in their compressed state during their insertion and allow or cause the stent structures to expand once they are in their desired location. The methods may include implantation of the stent structures using either an antegrade or retrograde approach.
One embodiment of a stent of the invention comprises a tubular wire structure including multiple wires that extend generally in the direction of the longitudinal axis of the stent. A bioprosthesis can be attached to the wires of this stent in certain, predetermined locations and preferably will be sewn to the wires in such a way that the material from which the bioprosthesis is made will not be damaged during compression and/or expansion of the stent and attached bioprosthesis. In one embodiment, the stent includes three commissure attachment areas, where each of these areas is used as a connection location for one of the commissure extensions of a bioprosthesis.
The stented valves of the invention can use an external tubular material, such as a bovine jugular vain, pericardial tissue, PTFE graft material, polyester cloth, and other materials, to facilitate attachment of leaflets to the stent or tubular material. Attachment options can then be used that differ from using direct attachment of leaflets to the stent structure. In this way, the stent may not be as subject to long term fatigue of its valve leaflets because the loading forces on the leaflet attachment locations are transferred from a rigid stent structure to a flexible tubular structure.
The present invention will be further explained with reference to the appended Figures, wherein like structure is referred to by like numerals throughout the several views, and wherein:
As referred to herein, the prosthetic heart valves used in accordance with the various devices and methods of heart valve delivery of the invention may include a wide variety of different configurations, such as a prosthetic heart valve having tissue leaflets or a synthetic heart valve having polymeric, metallic, or tissue-engineered leaflets, and can be specifically configured for replacing any heart valve. That is, while much of the description herein refers to replacement of aortic valves, the prosthetic heart valves of the invention can also generally be used for replacement of native mitral, pulmonic, or tricuspid valves, for use as a venous valve, or to replace a failed bioprosthesis, such as in the area of an aortic valve or mitral valve, for example.
In general, the stents described herein include a support structure comprising a number of strut or wire portions arranged relative to each other to provide a desired compressibility, strength, and leaflet attachment zone(s) to the heart valve. Other details on particular configurations of the stents of the invention are also described below; however, in general terms, stents of the invention are generally tubular support structures, and a bioprosthesis will be secured within the inner area of the tubular support structure to provide a valved stent.
In more general terms, the combination of a support structure with one or more leaflets of a bioprosthesis can assume a variety of other configurations that differ from those shown and described, including any known prosthetic heart valve design. In certain embodiments of the invention, the support structure with leaflets utilize certain features of known expandable prosthetic heart valve configurations, whether balloon expandable, self-expanding, or unfurling (as described, for example, in U.S. Pat. Nos. 3,671,979; 4,056,854; 4,994,077; 5,332,402; 5,370,685; 5,397,351; 5,554,185; 5,855,601; and 6,168,614; U.S. Patent Application Publication No. 2004/0034411; Bonhoeffer P., et al., “Percutaneous Insertion of the Pulmonary Valve”, Pediatric Cardiology, 2002; 39:1664-1669; Anderson H R, et al., “Transluminal Implantation of Artificial Heart Valves”, EUR Heart J., 1992; 13:704-708; Anderson, J. R., et al., “Transluminal Catheter Implantation of New Expandable Artificial Cardiac Valve”, EUR Heart J., 1990, 11: (Suppl) 224a; Hilbert S. L., “Evaluation of Explanted Polyurethane Trileaflet Cardiac Valve Prosthesis”, J Thorac Cardiovascular Surgery, 1989; 94:419-29; Block P C, “Clinical and Hemodynamic Follow-Up After Percutaneous Aortic Valvuloplasty in the Elderly”, The American Journal of Cardiology, Vol. 62, Oct. 1, 1998; Boudjemline, Y., “Steps Toward Percutaneous Aortic Valve Replacement”, Circulation, 2002; 105:775-558; Bonhoeffer, P., “Transcatheter Implantation of a Bovine Valve in Pulmonary Position, a Lamb Study”, Circulation, 2000:102:813-816; Boudjemline, Y., “Percutaneous Implantation of a Valve in the Descending Aorta In Lambs”, EUR Heart J, 2002; 23:1045-1049; Kulkinski, D., “Future Horizons in Surgical Aortic Valve Replacement: Lessons Learned During the Early Stages of Developing a Transluminal Implantation Technique”, ASAIO J, 2004; 50:364-68; the teachings of which are all incorporated herein by reference).
Orientation and positioning of the valves of the invention in a patient may be accomplished either by self-orientation of the stents (such as by interference between features of the stent and a previously implanted stent or valve structure) or by manual orientation of the stent to align its features with anatomical features or features of a previously implanted bioprosthetic structure, such as can be accomplished using fluoroscopic visualization techniques, for example. For example, when aligning the stents of the invention with native anatomical structures, they should be aligned so as to not block the coronary arteries, and native mitral or tricuspid valves should be aligned relative to the anterior leaflet and/or the trigones/commissures to allow normal functioning of these structures.
Some embodiments of the support structures of the stents described herein can comprise a series of wires or wire segments arranged so that they are capable of transitioning from a collapsed state to an expanded state. In some embodiments, a number of individual wires comprising the support structure can be formed of a metal or other material. These wires are arranged in such a way allows for folding or compressing the support structure to a contracted state in which its internal diameter is greatly reduced from its internal diameter when it is in an expanded state. In its collapsed state, such a support structure with attached valves or leaflets can be mounted over a delivery device, such as a balloon catheter, for example. The support structure is configured so that it can be changed to its expanded state when desired, such as by the expansion of a balloon catheter. The delivery systems used for such a stent should be provided with degrees of rotational and axial orientation capabilities in order to properly position the stent at its desired location within the patient.
The wires of the support structure of the stents in other embodiments can alternatively be formed from a shape memory material such as a nickel titanium alloy (e.g., Nitinol). With this material, the support structure is self-expandable from a contracted state to an expanded state, such as by the application of heat, energy, and the like, or by the removal of external forces (e.g., compressive forces). This support structure can also be repeatedly compressed and re-expanded without damaging the structure of the stent. In addition, the support structure of such an embodiment may be laser cut from a single piece of material or may be assembled from a number of different components. For these types of stent structures, one example of a delivery system that can be used includes a catheter with a retractable sheath that covers the stent until it is to be deployed, at which point the sheath can be retracted to allow the stent to expand.
Referring now to the Figures, wherein the components are labeled with like numerals throughout the several Figures, and initially to
In accordance with the invention, each of the commissure extensions 44 is attached to a V-shaped structure 54 with stitches that are spaced from each other and extend along the both sides and the peak of each structure 54. The stitching can be performed using standard suture material, which has a first end that can be terminated at one end of each structure 54 and a second end that can be terminated at the other end of the same structure 54, for example. Alternatively, a different stitching pattern can be used. The bioprosthesis 40 is additionally secured at its inflow end 42 to the stent frame 50 by suturing the covering material 48 and/or the tubing material to the diamond-shaped structures 52 in a zigzag pattern, as shown. While these figures only illustrate stitching along the lower portion or edge of each of the structures 52, the inflow end 42 could be additionally secured by stitching along the upper portion or edge of the structures 52. However, the stitching pattern illustrated in
In one embodiment, the stent 100 is generally tubular in shape and includes multiple longitudinal or vertical wires 102 that extend generally parallel to a longitudinal axis 104 of the stent. The wires 102 are spaced from each other around the periphery of the generally tubular shape of the stent 100. Stent 100 further includes features to which tissue can be attached to make the stent into a valve, such as commissure attachment posts 106. Commissure attachment posts 106 can each include two longitudinal wires that are spaced closer to each other than the spacing of the wires 102 from each other.
In this embodiment, stent 100 includes three commissure attachment posts 106, where each of the posts 106 can be used as a connection location for one of the commissure extensions of a bioprosthesis, such as extensions 44 of bioprosthesis 40. Alternatively, more or less than three posts 106 can be provided for a valve having more or less than three leaflets, respectively. In addition to providing the structure for attachment of commissures, the posts 106 also provide additional stability to the stent 100. Stent 100 further includes multiple V-shaped wire structures 108 between pairs of wires 102 and/or between a wire 102 and an adjacent attachment post 106. Although the stent 100 is shown as having three of these V-shaped wires 108 spaced longitudinally from each other between adjacent vertical wire structures, there instead may be more or less than three V-shaped wires. All or some of the wires 108 can be flared at least slightly outward relative to the outer tubular shape of the stent 100, thereby creating integrated flange structures that can be used to capture the native leaflets when the stent is implanted in a patient.
Additional wire structures 122 are positioned at an end 120 of the stent 100, which are generally V-shaped, with the peak of each of the “V” structures oriented in generally the same direction as the peaks of the wires 108. All or some of these wire structures 122 are also flared at least slightly outward relative to the outer tubular shape of the stent 100. The amount and angle at which the various wire structures extend relative to the tubular outer shape of the stent can be selected for capturing native patient anatomical features. In addition, the flare of the wire structures 122 can help to prevent or minimize leakage between the implant and the native annulus and/or to provide a physical and/or visual docking feature to secure the stent 100 against a wall of an opening in the heart to prevent migration of the stent, for example.
One end of all or some of the wires 102 and posts 106 can further include a loop or eyelet 126 that can be used for attachment to a delivery system and/or tissue valve, for example. The single-sided eyelet attachment end can be used in a resheathable delivery system for both antegrade and retrograde procedures, for example.
This embodiment of a stent includes spaces or openings 110 that are created by the use of horizontal members 112 between the two wires that make up the attachment posts 106. These openings 110 provide locations through which suture material, needles, and/or other fastening materials can be inserted for attachment of the bioprosthesis to the stent frame. In addition, the horizontal members 112 can be used as defined anchoring points for the fastening materials. For example, a suture material can be inserted through a first opening 110 and then through another opening 110 in a predetermined pattern to stitch valve material to the commissure extensions of the bioprosthesis. The horizontal members 112 can further be used as anchoring structures that limit vertical movement of sutures or other attachment mechanisms. In order to attach other areas of the bioprosthesis to the stent 100, the scalloped areas, such as those described above relative to bioprosthesis 40, can be stitched along selected wires of the stent 100, such as along certain shaped wires 108 and/or vertical wires 102, for example.
A number of systems, components, and devices are described below for attachment of valve material (e.g., tissue leaflets) within the interior area of a stent structure. It is understood that the systems that are shown and described herein for this purpose can be used with stent configurations described above and/or other stent constructions.
It is noted that in many of the stent embodiments shown and described herein, the aspect ratio of certain portions of the stent can be somewhat different from that shown. Further, stent embodiments described herein may be modified to include additional structure for attachment of tissue for the valve, such as the vertical stent posts described in many of the embodiments.
Points along the edge of each scalloped opening 162 of the bioprosthesis 160 are attached to certain, predetermined wires of the stent 150. In the illustrated embodiment, the stent 150 includes a number of wires arranged into relatively narrow V-shaped structures 152 that extend longitudinally relative to a central axis of the stent 150. In this embodiment, the stent 150 is provided with one V-shaped structure 152 to correspond with each commissure extension 164, and one V-shaped structure 152 to correspond with each of the areas between the extensions 164 (e.g., scalloped areas 162). The stitching pattern used to attach the bioprosthesis to the stent includes providing stitches that can slide along the V-shaped structures to allow for movement of the components relative to each other during the compression and expansion of the bioprosthesis and to allow for the necessary dimensional changes of the stent and its attached bioprosthesis. This movement of the stitches along the stent wires will prevent or minimize stresses that might otherwise be placed on stitches having a smaller available range of motion when the components are being reconfigured during compression and/or expansion of the device.
Delivering any balloon-expandable stents of the invention to the implantation location can be performed percutaneously. In general terms, this includes providing a transcatheter assembly, including a delivery catheter, a balloon catheter, and a guide wire. Some delivery catheters of this type are known in the art, and define a lumen within which the balloon catheter is received. The balloon catheter, in turn, defines a lumen within which the guide wire is slideably disposed. Further, the balloon catheter includes a balloon that is fluidly connected to an inflation source. It is noted that if the stent being implanted is a self-expanding type of stent, the balloon would not be needed and a sheath or other restraining means would be used for maintaining the stent in its compressed state until deployment of the stent, as described herein. In any case, for a balloon-expandable stent, such as stent 150 of
Prior to delivery, the stent is mounted over the balloon in a contracted state to be as small as possible without causing permanent deformation of the stent structure. As compared to the expanded state, the support structure is compressed onto itself and the balloon, thus defining a decreased inner diameter as compared to an inner diameter in the expanded state. While this description is related to the delivery of a balloon-expandable stent, the same basic procedures can also be applicable to a self-expanding stent, where the delivery system would not necessarily include a balloon and expansion thereof, but would preferably include the use of a sheath or some other type of configuration for maintaining the stent in a compressed condition until it is released for deployment.
With the stent mounted to the balloon, the transcatheter assembly is delivered through a percutaneous opening (not shown) in the patient via the delivery catheter. The implantation location is located by inserting the guide wire into the patient, which guide wire extends from a distal end of the delivery catheter, with the balloon catheter otherwise retracted within the delivery catheter. The balloon catheter is then advanced distally from the delivery catheter along the guide wire, with the balloon and stent positioned relative to the implantation location. In an alternative embodiment, the stent is delivered to an implantation location via a minimally invasive surgical incision (i.e., non-percutaneously). In another alternative embodiment, the stent is delivered via open heart/chest surgery. In one embodiment of the stents of the invention, the stent includes a radiopaque, echogenic, or MRI visible material to facilitate visual confirmation of proper placement of the stent. Alternatively, other known surgical visual aids can be incorporated into the stent. The techniques described relative to placement of the stent within the heart can be used both to monitor and correct the placement of the stent in a longitudinal direction relative to the length of the anatomical structure in which it is positioned.
Once the stent is properly positioned, the balloon catheter is operated to inflate the balloon, thus transitioning the stent to an expanded state. Alternatively, where the support structure is formed of a shape memory material, the stent can be allowed to expand to its expanded state by removal of the external forces (e.g., a sheath).
The present invention has now been described with reference to several embodiments thereof. The foregoing detailed description and examples have been given for clarity of understanding only. No unnecessary limitations are to be understood therefrom. It will be apparent to those skilled in the art that many changes can be made in the embodiments described without departing from the scope of the invention. Thus, the scope of the present invention should not be limited to the structures described herein, but only by the structures described by the language of the claims and the equivalents of those structures.